The child being consigned to the arms of an attendant, the hand of the accoucheur is to be placed upon the patient's abdomen, and pretty firm pressure made, in order that the uterus may be felt. If it be found small and hard, we may be certain that it contains no other foetus, and the probability is that the placenta is expelled from its cavity; and this I will generally be found to be the case where due attention has been paid to the tightening of the bandage, and due care taken to retard rather than to burry the birth of the lower extremities of the child. In order to be certain, however, with regard to the placenta, an internal examination is required, when, if detached, it will very readily be felt at the upper part of the vagina, sometimes resting upon the symphysis pubis. From this situation it may be removed without difficulty, by twisting the funis round the left hand, and making slight extension downwards and backwards in the direction of the axis of the brim, whilst, with the fore and middle fingers of the right band, it is tilted into the concavity of the sacrum; thus imitating the passage of the head. When brought through the external parts, it should be received upon a napkin, in which it is to be wrapped up under the bedclothes, from whence it may be conveyed into any convenient receptacle.
This effect may be produced by three different causes:
1st. Torpidity of the uterus;
2d. Spasmodic action;
3dly. Adhesion of the placenta to the parietes of the uterus.
1st, Torpidity or inaction of the womb generally occurs from an exhausted state of the organ, in consequence of a protracted labour. When the hand is placed upon the abdomen, it will be large, flaccid, and flabby: the uterus being uncontracted, of course no hard tumor is perceptible, If the finger be passed into the vagina, the cord may be traced within the os uteri, but no placenta can be felt.
Treatment. Some nourishment may be given the patient, and brisk friction employed over the uterine region, If this does not prove effectual, (which, however, it usually does,) half a drachm of powdered ergot may be given in warm tea.
2d. Spasmodic action. If the placenta be retained from this cause, the patient will complain of constant pain; and, if the hand be so placed upon the abdomen as to grasp the uterus, it will be found to be hard and contracted in one part, soft and flabby in another. Sometimes contraction of those fibres situated around the centre of the organ alone takes place, whilst the others remain relaxed, which must necessarily have the effect of dividing the uterus into two chambers, and then, from its shape, it is termed the hourglass contraction. This is, however, of rare occurrence: it is much more common for the circular fibres to contract pretty generally, whilst the longitudinal remain relaxed; and the placenta will then be completely shut up within the uterine cavity. If the uterus be examined through the abdominal coverings, it will be felt hard and of large size. The cord may also be traced with the finger, passing through the contracted os uteri, whilst the vagina remains relaxed below; and this state of parts has been often confounded with hourglass contraction.
Treatment. Friction to the abdomen, and the application of cloths dipped in cold water. As a last resource, the introduction of the hand into the uterus, the dilatation of the strictured part, and the removal of the placenta. In very obstinate cases, a full dose of opium is necessary.
3d. From adhesion. When, after delivery, the patient continues to have strong uterine action, (and this is ascertained by pressing upon the abdomen,) and the placenta remains behind, there is reason to believe that there is an unnatural adhesion to the sides of the womb.
Treatment. After waiting an hour, if it be not expelled, the hand may be very cautiously introduced, the placenta separated, and brought away. If hemorrhage occur, no time should be lost; the hand must be introduced instantly.
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From Charles Waller
Elements of Practical Midwifery: Or, Companion to the Lying-in Room, 1829
